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Approaches to prevention and management of Trabeculectomy Complications
Moaz Suleiman
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Objectives – Glaucoma Surgery
To describe the options available to lower IOP with incisional surgery To understand the following with respect to trabeculectomy surgery: Essential principles of surgery Prevention of complications Recognition and management of intra-op, early, and late post-op complications
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Choice of Glaucoma Surgery
Degree of optic nerve and VF damage Target IOP range Mechanism of glaucoma Visual Potential Risk for devastating intra-op and post-op complications Cataract Discussion with the patient
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Incisional Glaucoma Surgery Options
Enhance Outflow: Physiological pathways: Trabecular meshwork- trabectome Schlemm’s canal – istent, ipass, icath Suprachoroidal space - Gold shunt Subconjunctival drainage: Trabeculectomy Aqueous drainage device Reduce inflow: Endoscopic /External cyclophotocoagulation Combined: Cataract extraction/IOL & one of the above
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Peng Khaw Technique
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Pre- and Intra-operative
Outline Trabeculectomy Complications Recognition and initial management Complications Pre- and Intra-operative Post-operative
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Pre-operative Complication
Retrobulbar Hemorrhage Urgent action required Risk of extrusion of intraocular contents May proceed only if limited and IOP not elevated Management Check IOP, status of CRA IV mannitol or diamox Lateral canthotomy and cantholysis Orbital decompression Infracture of medial inferior wall with hemostat
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Prevention - Good exposure
Adequate anesthesia Lid retraction Bridle or corneal suture
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Intra-operative Complications
Conjunctival Buttonhole Prevention Treat conjunctiva with RC! Non-toothed forceps Broad based grip Early in surgery Consider changing site of surgery Late in surgery Horizontal mattress suture (10.0 nylon or 9.0 vicryl on a vascular needle)
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Intra-operative Complications
Flap Disinsertion or Tear Attempt replacement Suture with 10.0 nylon Scleral patch graft Different location Flap hole Suture if possible Patch with tenon’s capsule Manage as a full thickness fistula i.e. expect hypotony for some time postop Healon GV in AC if appropriate
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Intra-operative Complications
Vitreous Loss May be early sign of suprachoroidal hemorrhage Anterior vitrectomy Ensure vitreous is cleared from incision – Weck cell or automated vitrectomy
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Intra-operative Complications – Bleeding
Choroidal hemorrhage Risk factors Ocular hypotony Advanced age Arteriosclerosis - HTN Aphakia or myopia Nanophthalmos (~30% risk) Elevated EVP Anti-coagulants High pre-op IOP >40mmHg give IV mannitol Choroidal hemangiomas Sturge Weber (~30% risk)
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Intra-operative Complications – Bleeding
Choroidal hemorrhage Signs sudden increase in firmness of eye flattening of the AC forward movement of intraocular contents Loss of red reflex Treatment Close eye Consider pre-placing flap sutures Consider scleral drainage 3-4 mm posterior to limbus
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Prevention - suprachoroidal hemorrhage
May wish to avoid filtering surgery in favor of valved drainage device, cyclophotocoagulation Pre-operative considerations: Can anti-coagulation be safely discontinued? Mannitol or diamox to lower IOP Intra-operative considerations: Consider prophylactic posterior sclerotomy Slow decompression of eye via paracentesis Avoid Large IOP drops intra-op Excessive tissue distortion Prolonged hypotony
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Prevention – Hypotony Firmly closed scleral flap
Test flow after closure of sclera Meticulous, watertight closure of Tenon and conjunctiva (in separate layer if possible) After conjunctival closure, apply 2% flourescein and look for leaks If, after BSS injection, AC still shallows significantly considering injecting Healon GV
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Intra-operative Complications – Bleeding
Iris root or ciliary body bleeding May cause blockage of internal os Management Cold BSS Wet field 23G cautery Tamponade with Weck cells or viscoelastic Tight closure with extra sutures
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Prevention - minimize Bleeding
Avoid anterior ciliary arteries Use gentle bipolar cautery Avoid bleeding from ciliary body – may need to dissect and enter more anteriorly than planned
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Intra-operative Complications – Bleeding
Hyphema Severe Washout Minimal to moderate Minimal irrigation May leave
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Post-Operative Complications
Early Late Any IOP Low IOP High IOP
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Post-Operative Complications
Early Any IOP Low IOP High IOP
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Post-Operative Complications
Early Any IOP Low IOP High IOP Hyphema Dellen Uveitis
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Post-Operative Complications
Early Any IOP Low IOP High IOP Hyphema Uveitis Dellen Usually conservative management Wait it out Identify bleeding vessels Argon laser Severe May need washout
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Post-Operative Complications
Early Any IOP Low IOP High IOP Hyphema Uveitis Dellen Treat aggressively Steroids Atropine
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Post-Operative Complications
Early Any IOP Low IOP High IOP Hyphema Uveitis Dellen Lubrication
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Post-Operative Complications
Early Any IOP Low IOP High IOP Formed Bleb Flat Bleb
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Post-Operative Complications
Early Any IOP Low IOP High IOP Formed Bleb Flat Bleb Over filtration Management Atropine 1% Decrease steroids +/- Aqueous suppressants +/- Gentamycin invoke inflammation Torpedo patch Pressure patch Oversized SCL Prolonged Reform chamber Healon GV Surgical revision Cause Loose flap
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Post-Operative Complications
Early Any IOP Low IOP High IOP Formed Bleb Flat Bleb Wound Leak Patch Large diameter SCL Gentamycin drops (small leaks) invoke an inflammatory response Surgical repair (larger holes)
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Early Post-Operative: Low IOP
Any IOP Low IOP High IOP Choroidal effusions Setting of hypotony Chamber can be deep or shallow Choroidals themselves contribute to hypotony Will resolve with increased IOP
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Early Post-Operative: Low IOP
Any IOP Low IOP High IOP Choroidal effusions Must address underlying cause Wound leak Loose flap Management Healon GV in AC initially Surgical drainage
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Early Post-Operative: Low IOP
Any IOP Low IOP High IOP “Kissing” choroidals Urgent drainage Adhesions within 24 – 48 hours May cause central flattening of chamber Lens/Cornea damage
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Early Post-Operative: Low IOP – Normal Bleb
Any IOP Low IOP High IOP CB Shutdown or detachment Cyclodialysis Cleft Retinal Detachment
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Early Post-Operative: Low IOP – Normal Bleb
Any IOP Low IOP High IOP CB Shutdown Cyclodialysis Cleft Excessive inflammation Steroids Atropine Avoid beta blockers, CAI inhibitors
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Early Post-Operative: Low IOP – Normal Bleb
Any IOP Low IOP High IOP CB Shutdown Cyclodialysis Cleft Identify with gonio or UBM Atropine, decrease steroids Argon laser with Goldmann lens Treat the scleral region of the cleft For large cleft, definitive management is surgical repair
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Post-Operative Complications
Early Any IOP Low IOP High IOP Deep Chamber Flat Chamber
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Post-Operative Complications
Early Any IOP Low IOP High IOP Deep Chamber Flat Chamber Internal Blockage Tight Flap External Blockage
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Post-Operative Complications
Early Any IOP Low IOP High IOP Deep Chamber Flat Chamber Internal Blockage Tight Flap External Blockage Identify with gonio Iris Blood Uvea Vitreous Manage based on etiology Steroids TPA Disengage iris (laser, mechanical) Revision
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Post-Operative Complications
Early Any IOP Low IOP High IOP Deep Chamber Flat Chamber Internal Blockage Tight Flap External Blockage Digital massage after 48 hours Suture lysis Argon green Window is ~ 1-4 weeks Longer with MMC
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Post-Operative Complications
Early Any IOP Low IOP High IOP Deep Chamber Flat Chamber Internal Blockage Tight Flap External Blockage Blood/fibrin Early Encapsulation
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Post-Operative Complications
Early Any IOP Low IOP High IOP Deep Chamber Flat Chamber Pupillary Block Suprachoroidal hemorrhage Aqueous misdirection
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Post-Operative Complications
Early Any IOP Low IOP High IOP Deep Chamber Flat Chamber Pupillary Block Suprachoroidal hemorrhage Aqueous misdirection PI at time of surgery rule out Management: Laser PI
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Post-Operative Complications
Early Any IOP Low IOP High IOP Deep Chamber Flat Chamber Pupillary Block Suprachoroidal hemorrhage Aqueous misdirection hours post-op in a hypotonous eye Dark choroidal swelling Typical symptoms pain nausea and/or vomiting
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Post-Operative Complications
Early Any IOP Low IOP High IOP Deep Chamber Flat Chamber Pupillary Block Suprachoroidal hemorrhage Aqueous misdirection Diagnosis Indirect B-scan Management May observe IOP OK No central touch Drainage at days PRN
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Post-Operative Complications
Early Any IOP Low IOP High IOP Deep Chamber Flat Chamber Pupillary Block Suprachoroidal hemorrhage Aqueous misdirection Very shallow or flat central AC Aqueous suppressants Cycloplegia (A1%, BID) 50% resolve YAG anterior vitreous face (aphakic/pseudophakic) Pars plana vitrectomy
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Post-Operative Complications
Late Any IOP Low IOP High IOP
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Post-Operative Complications
Late Any IOP Low IOP High IOP Cataract Infection Uncomfortable Bleb
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Post-Operative Complications
Late Any IOP Low IOP High IOP Cataract Uncomfortable Bleb Infection Surgical Management
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Post-Operative Complications
Late Any IOP Low IOP High IOP Cataract Uncomfortable Bleb Infection Lubricants Watch for loose sutures Eyelid riding high Gold weight Other lid procedure Revision
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Post-Operative Complications
Late Any IOP Low IOP High IOP Cataract Uncomfortable Bleb Infection Blebitis Endophthalmitis
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Question The major feature that distinguishes “blebitis” from endophthalmitis is: a. Appearance of the bleb b. Degree of conjunctival discharge c. Degree of pain d. Intraocular inflammatory reaction
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Late Post-Operative: Infectious
BLEBITIS ENDOPHTHALMITIS Pain + / ++ ++++ Vision Normal Decreased AC RXN 0-1+ 2-4+, hypopyon Vitreous RXN Never Hallmark Main differentiating feature: VITREAL INFLAMMATION in endophthalmitis
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Organisms – blebitis and endophthalmitis
Strep: can penetrate intact conjuctiva, can rapidly progress to endophthalmitis Staph Haemophilus influenzae Moraxella Pseudomonas Serratia
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Late Post-Operative: Infectious
Blebitis Treat aggressively with topical fortified antibiotics or broad spectrum fluoroquinolone PO Cipro Steroid in 48 hours Very close follow-up
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Late Post-Operative: Infectious
Endophthalmitis Different group from EVS Vitreous tap and intravitreal antibiotics Vancomycin 1 mg (10 mg/ml) Amikacin 400 micrograms in 0.1 ml Ceftriaxone 2mg in 0.1 ml, or Ceftazidime PPV – when to do it controversial Use fortified topical antibiotics as well Consider PO Ciprofloxacin Cycloplegia
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Prevention PATIENT EDUCATION!! Staff education RSVP
Red Sensitivity to light VA decline Pain Staff education Can mean the difference between blebitis and endophthalmitis!
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Late post-op – Any IOP Corneal dissection or overhang
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Post-Operative Complications
Late Any IOP Low IOP High IOP Hypotony Maculopathy Risk factors Male Young age High myopia
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Post-Operative Complications
Late Any IOP Low IOP High IOP Management – address underlying cause: Autologous blood injection Compression suture (corneal or incorporate bleb) Surgical revision (fresh conjunctiva with or without scleral patch graft) Amniotic membrane
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Post-Operative Complications
Late Any IOP Low IOP High IOP Internal Blockage Tight Flap External Blockage
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Post-Operative Complications
Late Any IOP Low IOP High IOP Internal Blockage Tight Flap External Blockage
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Post-Operative Complications
Late Any IOP Low IOP High IOP Internal Blockage Tight Flap External Blockage Delayed suture lysis Window is ~ 1-4 weeks Longer with MMC Bleb needling with 5-FU or MMC
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Post-Operative Complications
Late Any IOP Low IOP High IOP Internal Blockage Tight Flap External Blockage Bleb encapsulation Tenon’s cyst Conjunctival scarring May need re-op
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Late Post-Operative: High IOP
Tenon’s cyst: Treat IOP Allow 3 months for spontaneous resolution More aggressive management Needling 50% success Higher success if 5-FU or MMC Surgical excision
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Late Post-Operative: High IOP
Tenon’s cyst: Treat IOP Allow 3 months for spontaneous resolution More aggressive management Needling 50% success Higher success if 5-FU or MMC Surgical excision
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Late Post-Operative: High IOP
Failed bleb Treat IOP Restart meds More aggressive management Needling Approx. 50% success Higher success with 5-FU and MMC Surgical Repeat trab with MMC Glaucoma drainage device Other
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Post-Operative Complications
Summary Post-Operative Complications Early Late Any IOP Low IOP High IOP Any IOP Low IOP High IOP Overfiltering/leak or CB shutdown Hyphema Uveitis Dellen Formed Bleb Flat Bleb Deep Chamber Flat Chamber Cataract Uncomfortable Bleb Infection Internal Blockage Tight Flap External Blockage
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